Surgical management of left main coronary artery aneurysm.

Aneurysmal dilatation of coronary arteries is characterized by abnormal dilatation of a localized or diffuse segment of the coronary arterial tree. Left main coronary artery aneurysms are rare coronary anatomic abnormalities. They rarely involve the left main coronary artery. Different strategies have been adopted, where the coronary artery aneurysms have been left as such, resected partially, isolated, reconstructed, ligated with a simultaneous bypass with internal mammary artery, or treated with vein grafts. We report a case of a successful ligation of aneurysm of the left main coronary artery and three simultaneous coronary artery bypass procedures (Fig. 1, Ref. 15).

Effects of Nd-YAG Laser iridotomy on anterior segment measurements in pigment dispersion syndrome and ocular hypertension.

PURPOSE: To compare the anterior segment optical coherence tomography (AS-OCT) measurements of eyes with pigment dispersion syndrome (PDS) and ocular hypertension (OHT) before and after neodymium:yttrium-aluminum-garnet (Nd:YAG) laser peripheral iridotomy (LPI). METHODS: A total of 23 eyes of 23 patients with PDS and OHT with features of PDS were included in this retrospective study. All of the eyes with PDS and OHT were examined by AS-OCT before and after Nd:YAG LPI. Anterior chamber depth, angle opening distance 500, angle opening distance 750, trabecular iris space 500, trabecular iris space 750 and scleral spur angle, iris bowing and iris shape were measured with AS-OCT by the same examiner. RESULTS: The differences in all parameters before and after Nd:YAG LPI were statistically significant. Iris configuration was concave in all eyes prior to iridotomy. After Nd:YAG laser iridotomy, the iris configuration became convex in 7 eyes, flat in 9 eyes and remained concave in 7 eyes. CONCLUSION: Nd:YAG laser peripheral iridotomy is an effective method for reversing the iris concavity and iris bowing in pigment dispersion syndrome.

Analysis of retinal microvasculature in Fuchs' uveitis syndrome. Retinal microvasculature in Fuchs' uveitis.

PURPOSE: The objective of this study is to quantitatively analyse the foveal microvasculature in eyes with Fuchs' Uveitic Syndrome (FUS), or Fuchs' Heterochromic Iridocyclitis (FHI), by Optical coherence tomography angiography (OCTA). METHODS: Thirty patients with FUS and 30 healthy volunteer patients (control group) were enrolled in the study. Vascular density (VD) in the superior and deep capillary plexuses (SCP, DCP) were reported and compared between eyes with FUS (FU), fellow eyes (FE) and the control group. RESULTS: Foveal VD and parafoveal VDs in all quadrants of the SCP were significantly lower in the FU group than the FE group and normal eyes (P<0.05). Foveal VDs in the DCP were similar between the three groups (P>0.05); however, parafoveal VDs in all quadrants of the DCP were significantly lower in the FU group than in the FE and control eyes (P<0.05). Foveal and parafoveal VDs in both the SCP and DCP were similar between fellow eyes and the control group. CONCLUSION: Fuchs' Uveitic Syndrome (Fuchs' Heterochromic Iridocyclitis) affects not only the anterior uvea and vitreous but also the retinal microvasculature. Analysis by OCT-A may enable us to understand the extent of this disease.

A comparative evaluation of segmental analysis of macular layers in patients with early glaucoma, ocular hypertension, and healthy eyes.

PURPOSE: To compare macular layer thicknesses between early glaucoma, ocular hypertension, and healthy eyes and to evaluate the accuracy of spectralis optical coherence tomography (OCT) segmentation software in discriminating early glaucoma from ocular hypertension and healthy eyes. METHODS: OCT scans were performed using the standard macular and peripapillary retinal nerve fiber layer (pRNFL) protocols on the Spectralis-OCT. The following macular thickness parameters were compared in the inner and outer circles of the Early Treatment Diabetic Retinopathy Study: total macular thickness (MT), retinal nerve fiber layer (mRNFL), ganglion cell layer (mGCL), inner plexiform layer (mIPL), inner nuclear layer (mINL), outer plexiform layer (mOPL), outer nuclear layer (mONL) and ganglion cell complex (mGCC: sum of mRNFL, mGCL, and mIPL). Sectors and layers with the best area under the receiver operating characteristic curve (AUC) were determined and compared between groups. RESULTS: Of a total of 200 eyes included in this study, 64 eyes had primary open angle glaucoma, 69 had ocular hypertension, and 67 were healthy. Peripapillary RNFL was significantly thinner in the early glaucoma group (P<0.05). For the macular variables, there was a significant reduction in the MT, mGCC, mRNFL, mGCL, and mIPL thicknesses in the early glaucoma group; while there were no statistically significant differences between the ocular hypertension and control groups (P>0.05). For distinguishing early glaucoma from normal eyes, AUCs for mGCC, mGCL, and mRNFL were similar to the pRNFL; and for early glaucoma and ocular hypertension, AUCs for mGCC, mGCL mRNF and mIPL were comparable to the pRNFL. CONCLUSION: Macular segmentation can assist in the early diagnosis of glaucoma as a complementary study to pRNFL analysis.

Symptomatic bilateral carotid artery stenoses 7 years after coronary artery bypass surgery in a young patient with familial hypercholesterolemia.

We present a patient suffering from homozygous familial hypercholesterolemia, who developed coronary artery disease in the age of 15 treated with three vessels coronary artery bypass grafting (CABG) operation. 7 years after CABG surgery symptomatic bilateral carotid artery stenoses were observed. Both internal carotid arteries were stented. The combination of pharmacologic therapy with life-long LDL-apheresis is the current treatment of choice.

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common.

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Mycotic aneurysm of the descending aorta diagnosed by echocardiography.

We present a 3-yr-old girl with coarctation of aorta and patent ductus arteriosus in whom mycotic aneurysm and bacterial endarteritis developed postoperatively and was diagnosed by two-dimensional and Doppler echocardiography. Five weeks after the operation of ligation of ductus and resection of coarctated segment, the patient was readmitted with complaints of vomiting, fever and coughing. Bacterial endarteritis, empyema and septic arthritis were diagnosed. Suprasternal echocardiographic examination demonstrated an aneurysmatic appearance 60 x 65 mm in size at the location of coarctation. The patient died, most probably due to aortic rupture, before surgical treatment could be undertaken. Autopsy study confirmed our diagnosis.

Surgical treatment in tetralogy of Fallot diagnosed by echocardiography.

The purpose of this paper is to present the authors' 3-yr experience of echocardiographic examination of patients with the clinical diagnosis of tetralogy of Fallot, and their evaluation for surgical treatment without prior cardiac catheterization. Among the patients with the clinical diagnosis of tetralogy of Fallot 227 had a definite diagnosis made by M-mode, two-dimensional, Doppler and contrast echocardiography. For the diagnosis of tetralogy of Fallot, ventricular septal defect, pulmonary stenosis, and overriding of the aorta were considered to be fundamental. Ventricular septal defect could be seen easily in the subaortic region by two-dimensional echocardiography. However, in some patients whose ventricular septal defect was not seen clearly, peripheral vein contrast echocardiography was performed. The diameters of pulmonary artery, and main branches at a few millimeters distal to their origin were measured. These parameters were correlated with the aortic diameter for evaluation as to whether they were able to accept the total cardiac output. In patients whose left ventricular end-diastolic dimension was small, shunt operation was preferred. In 115 patients the pediatric cardiologist performing the echocardiography thought that cardiac catheterization was necessary. In these cases the reliability of echocardiography in detecting important cardiac abnormalities was evaluated. Detection of ventricular septal defect, presence of pulmonary valve, detection of stenosis on the pulmonary bifurcation and/or main branches revealed a high sensitivity. Two-hundred-and-one patients diagnosed by echocardiography underwent total correction. In all cases except one the preoperative diagnosis was confirmed by surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

An alternative repair technique for aortic periprosthetic leakage.

In case of aortic periprosthetic leakage, there are several methods of repair. When valve replacement or refixation is not suitable an alternative repair technique, 'curtaining' with a Dacron patch to prevent leakage is presented.

Familial atrial myxoma.

Familial and biatrial myxomas of the heart have rarely been described. We describe a familial atrial myxoma involving a parent with biatrial and a child with a left atrial myxoma. Atrial myxomas were diagnosed preoperatively by echocardiography and successfully removed at operation. Echocardiography can be used in the diagnosis of cardiac myxoma, detection of its possible recurrence and for screening other members of the family.

Right ventricular hydatid cyst causing recurrent pulmonary emboli.

A hydatid cyst of the heart is rare. Surgical treatment is the preferable method in the treatment of cardiac echinococcosis. A 27-year-old patient with right ventricular hydatid cyst causing recurrent pulmonary emboli and diagnosed by 2-dimensional echocardiography and treated surgically is presented.

A surgical approach on an emergency basis for removal of Wilms' tumor with intracardiac neoplastic extension.

Extension of Wilms' tumor through inferior vena cava into the heart two years after the completion of therapy, is a very rare clinical aspect. We successfully operated on a 7 year old girl who had a huge right atrial mass which filled the right ventricle and right ventricular out flow tract, on an emergency basis using cardiopulmonary bypass.

Isolated cardiac metastasis of osteosarcoma.

Osteosarcoma metastasis to the heart caused by tumor thrombosis is very rare. A 7-year-old girl with an osteosarcoma of the right humerus, refused the treatment, at first, then, 1 year later, referred to the hospital with metastasis to the heart. The mass invading the pulmonary arteries was successfully removed with open-heart surgery.

Myocardial metabolism during fixed-rate pulsatile left ventricular bypass.

Fixed-rate pulsatile cardiopulmonary bypass may improve subendocardial perfusion during ventricular fibrillation and has been employed during intermittent aortic cross-clamping. Variable-rate pulsatile left heart bypass that is governed by venous inflow and is asynchronous to the electrical activity of the heart is currently used in clinical practice. To study the effect of fixed-rate pulsation on myocardial metabolism during left heart bypass, six adult pigs underwent alternating periods of pulsatile (PLS) and nonpulsatile (NPLS) centrifugal pump left atrial-to-aortic bypass in randomized block design. Coronary sinus, aortic, and bypass circuit flows were recorded. Oxygen content and lactate concentration of coronary sinus and aortic blood were measured. Pulsatility index and pulse power index during pulsatile bypass were 4.4 and 4.7 (cycles/s)2, respectively. Percent bypass was maximal at a mean pulsation rate of 41.3 and averaged 92.2 and 91.3 for PLS and NPLS, respectively. Myocardial oxygen consumption per minute was reduced 14.3% during NPLS but was unchanged during PLS compared to control (CTRL). Percent lactate extraction was significantly lower than CTRL during NPLS only. Competition for inflow with the ejecting heart appeared to limit circuit pulsation rate and pulse power index. Fixed-rate pulsation is ineffective in reducing myocardial metabolism and should be avoided in left heart bypass.

The incidence and management of coronary ostial stenosis.

Coronary ostial stenosis in the absence of more peripheral coronary artery disease was present in four patients (0.093%) of 4298 angiograms performed on patients with coronary artery disease. Case reports of four patients undergoing coronary artery bypass graft surgery for isolated coronary ostial stenosis are presented and surgical techniques discussed. Three patients were young females (mean age 31 years). It is suggested that coronary ostial stenosis is a rare variant of coronary artery disease, more common in young women.

Significance of the whole blood activated clotting time in cardiopulmonary bypass.

Recent publications have described a poor correlation between whole blood activated clotting time (WBACT) values and plasma heparin levels during cardiopulmonary bypass (CPB). A prospective, controlled study was undertaken to investigate the variables which may influence the WBACT in this situation. Antithrombin III levels over a range of 35-93 u/dl did not influence either the WBACT value or plasma heparin level. However, reduced platelet function following infusion of prostacyclin (10 ng/kg/min prior to CPB and 20 ng/kg/min thereafter); platelet number (range 63-287 X 10(9)/l) and packed cell volume (range 16-30%) were found to correlate with the WBACT. It is concluded that in addition to the circulating plasma heparin level, the wide variations in platelet number, platelet function and packed cell volume which are frequently observed during cardiopulmonary bypass may also influence the WBACT value.

Blood cyst originating from tricuspid septal leaflet.

Successful removal of a blood cyst of the tricuspid valve in a 34 years old man is reported. The rarity of this cyst in an adult and diagnostic clues are discussed.

Coarctation of the aorta in infants and neonates: results and assessment of prognostic variables.

From 1984 until 1994, 75 consecutive patients younger than 12 months of age were operated on for coarctation of the aorta. We retrospectively analyzed predictive factors for morbidity and mortality, and also interaction between surgical procedures and recoarctation. Surgical procedures were as follows: resection with a traditional end-to-end (E-E) anastomosis in 55 patients (73.3%), prosthetic patch aortoplasty (PPA) in 12 patients (16%) and subclavian flap aortoplasty (SFA) in 8 patients (10.7%). Early mortality was 9.33% (7 patients). Logistic regression analysis proved that age at operation, associated anomalies of heart, type of coarctation, aortic arch hypoplasia and pulmonary banding were independent predictors of hospital death. Late mortality occurred in 7 patients (10.3%). Associated anomalies of heart were an independent prognostic factor for late mortality. Actuarial freedom from recoarctation at 1 year was 91% [confidence limits (CL): 82% to 97%] and 5 years were 74% (CL: 67% to 86%). Immediate postrepair gradient was equal after E-E anastomosis and other procedures. We conclude that the treatment of first choice in the management of coarctation of the aorta in infants is E-E anastomosis.

Replacement of aortic root with valved tubular prosthesis in a ten-year-old child with infective endocarditis--a case report.

Aortic root abscess, aneurysm of sinus Valsalva, severe aortic valve insufficiency, and a fragile aortic wall caused by infective endocarditis were found in a 10-year-old child. Aortic valve replacement was intended as a preoperative strategy, but one of modifications of Cabrol had to be used urgently because of aortic root rupture between right atrial and aortic connection just after pericardiotomy.